How Could Hospitalisations at the End of Life Have Been Avoided? A Qualitative Retrospective Study of the Perspectives of General Practitioners,Nurses and Family Carers

Background

Although many patients prefer to stay and die at home at the end of life, many are hospitalised. Little is known about how to avoid hospitalisations for patients living at home.

Aim

To describe how hospitalisation at the end of life can be avoided, from the perspective of the GPs, nurses and family carers.

Method

A qualitative design with face-to-face interviews was used. Taking 30 cases of patients who died non-suddenly, 26 GPs, 15 nurses and 18 family carers were interviewed in depth. Of the 30 patients, 20 were hospitalised and 10 were not hospitalised in the last three months of life.

Results

Five key themes that could help avoid hospitalisation at the end of life emerged from the interviews. The key themes were: 1) marking the approach of death, and shifting the mindset; 2) being able to provide acute treatment and care at home; 3) anticipatory discussions and interventions to deal with expected severe problems; 4) guiding and monitoring the patient and family in a holistic way through the illness trajectory; 5) continuity of treatment and care at home. If these five key themes are adopted in an interrelated way, this could help avoid hospitalisations, according to GPs, nurses and family carers.

Conclusions

The five key themes described in this study can be seen as strategies that could help in avoiding hospitalisation at the end of life. It is recommended that for all patients residing at home, GPs and community nurses work together as a team from the moment that it is marked that death is approaching up to the end of life.     

The Postnatal Development of the Cerebellum— A fMRI and Silver Study

Summary The aim of this study was to evaluate the postnatal development of the cerebella of the pig and to compare this with the activation of the fMRI. The cells in the cerebella were studied by silver technique and the activation of the fMRI in the cerebella was initiated by flexion and extension of the hind paw. Our results showed an increase of the branching of the cells of the cerebellar cortex postnatally, coordinated with registration of fMRI active sites in the cerebella at 6-month postnatal. We concluded that the full maturation of the cerebella was around 6-month postnatal in the pig.     

Sleep Related Breathing Disorders and Inflammation — The Missing Link? A Cohort Study Evaluating the Interaction of Inflammation and Sleep Related Breathing Disorders and Effects of Treatment

Introduction

Sleep related breathing disorders (SRBD) are associated with both obesity and systemic inflammation. While the relationship between obesity and SRBD is established, the causality between inflammation and SRBD remains unclear. In this study we investigated the relation between SRBD and C-reactive protein (CRP) as a parameter of inflammation and the influence of SRBD treatment on CRP with additional regard to changes in metabolic and cardiovascular parameters.

Methods

Polysomnography (PSG) and laboratory data of patients diagnosed with SRBD over a period of 5 years were prospectively collected in a database and retrospectively analysed regarding the association of SRBD (according to apnoea-hypopnoea- index (AHI), duration of events and extent of desaturation) to CRP, blood pressure, cholesterol, fasting plasma glucose, HbA1c, quality of life measured via a visual analogue scale (VAS 0–100%), and the effects of SRBD therapy on these parameters.

Results

716 patients were included in the study, 171 with mild SRBD (AHI ≥5 to <15/h), 209 with moderate SRBD (AHI 15 to <30/h), 336 with severe SRBD (AHI ≥30/h). Results according to severity of SRBD. Severe SRBD was significantly associated with elevated levels of CRP (3.7 [1.8–7.0] mg/l, vs. moderate (p = 0.001), and mild SRBD (p<0.001), and higher prevalence of hypertension as compared to moderate and mild SRBD (p<0.001, respectively). Results in highly successful treatment. If SRBD treatment was highly successful (AHI <5/h), CRP and quality of life improved significantly (p = 0.001 and p = 0.002), as did blood pressure (p<0.001 for systolic and diastolic values), although BMI increased (p<0.001). Results in partially successful treatment. If success was defined as reduction of AHI of ≥50%, CRP also decreased (p<0.001), as did blood pressure (p<0.001). Again, BMI increased (p<0.001).

Conclusion

This is the first study to show an association of SRBD and CRP independently of BMI in a large cohort. The SRBD therapy-induced CRP decrease was not associated with BMI changes or metabolic changes but rather with the magnitude of AHI improvement.     

Tonsillectomy and the Risk for Deep Neck Infection—A Nationwide Cohort Study

Background

Although the tonsils contribute to first line immunity against foreign pathogens in the upper aero-digestive tract, the association of tonsillectomy with the risk of deep neck infection remains unclear. The aim of this study was to assess the incidence rate and risk of deep neck infection among patients who had undergone a tonsillectomy.

Methods

This retrospective cohort study evaluated all patients who had undergone tonsillectomy between 2001 and 2009 as identified from the Taiwan National Health Insurance Research Database. For each post-tonsillectomy patient, 10 age-, sex-, and index date-matched controls without a history of tonsillectomy were randomly selected. Cox Proportional hazard model and propensity score model were performed to evaluate the association between tonsillectomy and deep neck infection after adjusting for demographic and clinical data.

Results

There were 34 (71.6 cases per 100,000 person-years) and 174 (36.6 cases per 100,000 person-years) patients that developed deep neck infection in the tonsillectomized and comparison cohorts, respectively. After adjusting for covariates, patients who had undergone a tonsillectomy had a 1.71-fold greater risk of deep neck infection by both Cox proportional hazard model (95% confidence interval, 1.13-2.59) and propensity score model (95% confidence interval, 1.10-2.66). This association was not altered regardless of the indication for tonsillectomy (i.e. chronic/recurrent tonsillitis or sleep apnea/hypertrophy of tonsil) (p = 0.9797).

Conclusions

Based on our review of a nationwide cohort study we identified that the risk of deep neck infection is significantly increased among patients who have undergone a tonsillectomy. Additional research is needed to explore the possible mechanisms behind these findings.     

TREATMENT OF CANCER AND ALLIED DISEASES: Second Edition,Volume III—Tumors of the Head and Neck

In the absence of positive evidence that a single injury can cause cancer, the tendency is growing to award compensation to persons (particularly employees) with cancers alleged to have originated in trauma, even cancers which are generally conceded to be congenital in origin.Experimental attempts to induce cancer through trauma have been unsuccessful or doubtful in result. War-wounded persons, boxers and railroad accident victims have no higher incidence of cancer than other groups.Physicians and others in a position to educate the public should strive to dispel the error that cancer following injury is demonstrably or even probably the cause.     

The Developmental Instability—Sexual Selection Hypothesis: A General Evaluation and Case Study

Developmental instability results from small, random perturbations to developmental processes of individual traits. Phenotypic outcomes of developmental instability include fluctuating asymmetry (FA, subtle deviations from perfect bilateral symmetry) and phenodeviance (minor morphological abnormalities). A great deal of research over the past 18 years has focused on the role of developmental instability in sexual selection. A driving force behind this research has been the developmental instability-sexual selection hypothesis, which posits that symmetry and lack of phenodeviance in secondary sexual traits are assessed by mates and rivals because they provide a reliable cue of individual genetic quality. The present article tests this hypothesis by evaluating its five main predictions using published results: expressions of developmental instability in secondary sexual traits should be (1) negatively correlated with mating success; (2) directly assessed by mates and sexual rivals; (3) heritable; (4) condition-dependent; and (5) negatively correlated with ornament size. The first two predictions receive considerable, though not ubiquitous, support from a range of animal species. However, FA in secondary sexual traits is generally not significantly heritable, indicating that FA is unlikely to reveal genetic quality that can be transmitted to offspring. Similarly, there is little evidence to support the predictions that FA is condition dependent, and that it is negatively phenotypically or genetically correlated with sexual trait size. Based on an evaluation of the evidence overall, it is concluded that this hypothesis is unlikely to be viable; it appears unlikely that mate choice for symmetry evolves by “good genes” sexual selection. Hypotheses that do not require asymmetry and phenodeviance to reveal heritable genetic quality may explain observed links between FA/phenodeviance and mating success. Results of a case study of Drosophila bipectinata are summarized, which reinforce this general conclusion. It is suggested that nonadditive genetic variation arising from an interaction between trait-specific developmental genes and genetic background may drive sexual selection for reducing developmental instability in some cases. Levels of developmental instability variation in a population may need to surpass a critical threshold for sexual selection to operate, possibly explaining some of the pronounced heterogeneity in the effect of developmental instability on sexual selection reported in the literature.     

A Revision of Fritillaria L. (Liliaceae) in the Hengduan Mountains and Adjacent Regions,China ( 1 )—A Study of Fritillaria cirrhosa D. Don and Its Related Species

A study was made on Fritillaria cirrhosa D．Don and its related species based on both field observation and herbarium material．As a result,four species are recognized and 16 specific names and 18 variety names are reduced as synonyms．     

The Disconnect Between Knowledge and Perceptions: A Study of Fishermen’s Local Ecological Knowledge and Their Perception of the State of Fisheries and How These Are Managed in the Dominican Republic

Human Ecology - Understanding what fishers know about the ecology of the fish they catch, and how they perceive the state and management of their fisheries can guide efforts towards more...     

A Cytotaxonomic Study on Chinese Dioscorea L.—The Chromosome Numbers and Their Relation to the Origin and Evolution of the Genus

The chromosome numbers of 5 tuberous sections of Chinese Dioscorea, including 23 species and varieties, are reported in the present paper as a continuation of the previous reports. They are all polyploids with the basic number x=10. On the basis of analysis of chromosome numbers of whole genus, the rhizomatous diploid species of Sect. Stenophora Uline are presumed to be primitive taxa, while the polyploids of chromosome numbers 40-142 are considered derived groups as a result of hybridization between their ancestral diploids followed by chromosome doubling. Sect. Lasiophyton Pr. et Burk., Sect. Opsophyton UIine, Sect. Shannicorea Pr. et Burk., Sect. Combilium Pr. et Burk. and Sect. EnantiophylIum Uline may be the advanced groups. The chromosomal evolution and geographical distribution suggest that the primitivediploid might have originated in Hengduan Mountains of Asia, an old highland.     

General Practitioners’ Experiences of,and Responses to,Uncertainty in Prostate Cancer Screening: Insights from a Qualitative Study

BackgroundProstate-specific antigen (PSA) testing for prostate cancer is controversial. There are unresolved tensions and disagreements amongst experts, and clinical guidelines conflict. This both reflects and generates significant uncertainty about the appropriateness of screening. Little is known about general practitioners’ (GPs’) perspectives and experiences in relation to PSA testing of asymptomatic men. In this paper we asked the following questions: (1) What are the primary sources of uncertainty as described by GPs in the context of PSA testing? (2) How do GPs experience and respond to different sources of uncertainty?MethodsThis was a qualitative study that explored general practitioners’ current approaches to, and reasoning about, PSA testing of asymptomatic men. We draw on accounts generated from interviews with 69 general practitioners located in Australia (n = 40) and the United Kingdom (n = 29). The interviews were conducted in 2013–2014. Data were analysed using grounded theory methods. Uncertainty in PSA testing was identified as a core issue.FindingsAustralian GPs reported experiencing substantially more uncertainty than UK GPs. This seemed partly explainable by notable differences in conditions of practice between the two countries. Using Han et al’s taxonomy of uncertainty as an initial framework, we first outline the different sources of uncertainty GPs (mostly Australian) described encountering in relation to prostate cancer screening and what the uncertainty was about. We then suggest an extension to Han et al’s taxonomy based on our analysis of data relating to the varied ways that GPs manage uncertainties in the context of PSA testing. We outline three broad strategies: (1) taking charge of uncertainty; (2) engaging others in managing uncertainty; and (3) transferring the responsibility for reducing or managing some uncertainties to other parties.ConclusionOur analysis suggests some GPs experienced uncertainties associated with ambiguous guidance and the complexities of their situation as professionals with responsibilities to patients as considerably burdensome. This raises important questions about responsibility for uncertainty. In Australia in particular they feel insufficiently supported by the health care system to practice in ways that are recognisably consistent with ‘evidence based’ professional standards and appropriate for patients. More work is needed to clarify under what circumstances and how uncertainty should be communicated. Closer attention to different types and aspects of the uncertainty construct could be useful.     

The University of Manitoba Follow-up Study: A Prospective Investigation of Cardiovascular Disease: Part I. General Description—Mortality and Incidence of Coronary Heart Disease

A prospective study of cardiovascular disease was initiated in 1946 whereby 3983 healthy North American males, 91% under age 40, were subjected to periodic electrocardiograms and medical examinations between 1948 and 1963. The health of all but five of the 3773 survivors was known in 1963. There were 210 deaths: aircraft accidents accounted for 45%, cardiovascular disease 20%, cancer 11% and other causes 23%. The aggregate mortality closely resembled that of the Canadian Life Table 1955-57 (Male). Extra deaths were observed under age 40 owing to a high frequency of flying accidents. At older ages the mortality was lower than expected because congenital and chronic diseases were excluded at entry. One hundred and forty-three developed coronary heart disease. The case fatality rate was 31%. The incidence rate for coronary heart disease rose progressively from 0.277 per thousand per year for ages 25-34 to 26.5 at ages 60-69.